507001908-12-23-2021-27-AS-KHOS-CA5MDP-20211228083124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507001908
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:30:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2021 and conducted by Evaluator Arlene D Garcia

COMPLAINT CONTROL NUMBER: 27-AS-20211203154141

FACILITY NAME:	MODESTO GUEST HOME		FACILITY NUMBER:	507001908
ADMINISTRATOR:	GUILLERMINA ZEPEDA		FACILITY TYPE:	740
ADDRESS:	1344 E. ORANGEBURG AVENUE		TELEPHONE:	(209) 571-0116
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	31	CENSUS: 30	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Guillermina Zepeda, Administrator (AD)		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff handle resident in care in a rough manner.
Facility is not safeguarding resident(s) belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced complaint visit on this day for the purpose of concluding a complaint investigation. On this day LPA met with Guillermina Zepeda, Administrator (AD) and advised the purpose of LPA's visit.

The initial 10-day visit was conducted on 12/8/2021.

Through the course of the investigation, LPAs conducted interviews and reviewed staff and resident records.
It was alleged that the staff handle resident in care in a rough manner. LPA interviewed representatives from PACE that provided direct support services to residents that PACE places at the facility. PACE representatives stated they have placed residents in care at facility in the past and have had no concerns of the care being provided from the facility. PACE representatives confirm they visit 3x per week and have not observed any concerns. PACE stated residents come to their facility and have not observed any concerns of the residents when at their facility. LPA attempted to conduct interviews with residents. LPA was only able to interview 1 of the 5 residents as not all residents were able to be interviewed due to inability to be a reliable historian. LPA interviewed responsible parties and staff of R1 who stated that R1 is not a reliable historian. LPA toured facility and observed residents were being cared for properly. It was unclear if staff handle resident in care in a rough manner as alleged. Due to this uncertainty, the allegation that staff handle resident in care in a rough manner was deemed unsubstantiated.

CONT. >>>>>>>>>>>>>>>>>

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211203154141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MODESTO GUEST HOME	FACILITY NUMBER: 507001908
	VISIT DATE: 12/22/2021

NARRATIVE

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It was alleged that facility is not safeguarding resident(s) belongings. It was reported by R1 that items were missing when facility brought R1 to hospital. Interviews conducted with responsible party of R1 confirm items were not missing and found by the nurse at the hospital. LPA toured the facility and found residents belongings and personal effects in their rooms. Interviews conducted confirm R2 concerned of R2s belongings when R2 is given a shower. Through interviews, facility has a procedure to ensure R2 feels R2s belongings are safeguarded. Not all clients could be interviewed due to inability to be a reliable historian. It was unclear if facility is not safeguarding resident(s) belongings as alleged. Due to this uncertainty, the allegation that facility is not safeguarding resident(s) belongings was deemed unsubstantiated.

Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

Copy of this report provided to Administrator Guillermina Zepeda, Administrator (AD).

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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